A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, April 17, 2008

"End of Life" Care Costs: A Logical Fallacy

A joke:

Man gets on a bus in a strange town and asks the kid sitting next to him, "Which stop is Main Street?" Kid answers, "It's three stops before I get off."

An assertion:

More money is spent on medical care in the last year of life than at any other time (implying wasted resources on futile care.)

This statement may be true, but those who would then try to discuss means of decreasing this amount are losing sight of a critical distinction: the "last year of life" is a retrospectively defined time frame. And as the vast majority of oncologists will affirm, it is devilishly difficult -- if not impossible by definition -- to pin down that designation reliably in a prospective fashion.

I don't disagree that futile care is a huge problem in this country. Perhaps measures such as default DNR status for nursing home patients, or even more proactively, a prohibition on admitting them to an acute care facility might put a dent in the sum expended. Even if we were better able to address the unreasonable expectations of the families of clearly terminal dementia patients (thus eliminating all those "senile grannies" that seem to be the bane of existence for Panda, White Coat and the Happy Hospitalist) I don't think we'd see much of a dent in those dollars; at least not nearly as much as many professionals in the acute care setting seem to think we would.

However you look at it, most people get sick before they die. (Though I'm reminded at this juncture of Health Business Blog's David Williams' pithy comment, "For all its disadvantages, sudden death is cheap to treat.") When they get sick, they go to doctors (NOT always to emergency rooms, believe it or not.) Doctors then try to figure out what's wrong; this often involves testing, imaging and consulting with other doctors. When a diagnosis is made, especially a serious one, treatment is then undertaken. Costs for treatments like surgery, prescription medication, various therapies and so on add up quickly. By the time it becomes clear (perhaps) to some or all involved that the patient is not going to recover from the condition, the expenses have already been incurred.

Not only that, but patients often get well. Treatments sometimes work. Most of the time it is not possible to tell at the beginning of treatment how the patient is going to respond. Yet when they don't and the patient succumbs, some government accountant looks back and complains about "all that money spent in the last month of life," an example of perfect hindsight.

Obviously one key is to improve our prognostic skills while remaining ever vigilant about limiting truly futile care. But how to go about it? How about this: At the time of each hospitalization, the admitting physician makes a guess -- say on a scale of 1 to 100% -- about what he thinks the patient's chances are of living to be discharged from the hospital. Routine elective surgeries would probably garner a rating of 99% (to account for the ultimate unpredictability of everything.) Senile septic ancients might rate a 5% or lower. Don't formally publicize these guesses, but if everyone did it, over time we might very well find our predictive capacities improving. Eventually, physicians might feel empowered to limit aggressive care to those with very low likelihoods of survival. I know this sort of thing may be happening now on an informal basis, but if it were more systematized if might become easier to incorporate into policy.

How about the world of outpatients? Try this: At each patient visit, I generate my 1-100% guess that the patient will be alive after given time, whatever it is. A year; six months; three months; one month; doesn't matter. Formally determining a prognosis for every patient encounter; think about it. It doesn't seem appropriate for well baby care, but for COPD, CHF, CAD patients? Oncologists do this all the time (or at least they should;) why can't the rest of us? What about patients who are healthier, but with risk factors: hypertension; diabetes; sedentary lifestyles?

It's totally unfair -- not to mention illogical -- to bemoan money "wasted in the last year of life" without recognizing that they're talking about a bus that passed our street three stops ago. It's time to be more specific in our conversations about futile care; and a little more honesty and efforts to elevate our prognostic skills to try and approach the level of our diagnostic skills would be a better use of our time and efforts.

12 Comments:

Dinasaur, I can tell, with pretty good certainty who is going to survive till discharge, who is not, and who is going to live a miserable life of pain and suffering if they do survive. And I can usually tell this on the day of admission.

What a great post Dinosaur! Prognostication is my favorite medical subject, and probably one of the least understood clinical skills in medicine. Many doctors and the public take the cheap way out..."Oh you can never tell the future." And they are right but to a degree. Predicting future medical outcomes is not a binary proposition. It is not necessarily 'alive or dead.' If we only took that approach OF COURSE we will look inaccurate. BUt if we start working with proabilities and ranges, we can start to see pattterns, biases, errors, and more.

The kicker to all of this is that with feedbakc we can improve prognostication to help predict bad outcomes like death, BUT we can also start to research why things went right when we did not expect them to. Prognosis is a road map. It should tell you just about where you are going, and if you get off the road, we have to figure out how to get back on or accept that we are on a off road adventure.

For anyone wanting more info on prognosis (especially in EOL situations) Here are a couple of links:

Thanks for pointing out a lost skill of medicine and a common logical fallacy in EOL Care costs.

By the way, I prognosticate on every visit on rounds at our inpatient hospice facility and it is written in every note I do, and I will be hopefully publishing this as a new method of estimating clinical prediction of survival. And now I have your blog to cite!

I am convinced that if these families had to pay for even a fraction of this futile care a lot of this nonsense would stop on a dime. If that ever came to pass, it would stop the rationing that you know perfectly well WILL happen. In some countries it already does. I've been told that in Britian on the NHS pretty much everybody over the age of 70 is DNR.

I disagree. You can walk into the ICU and tell that about a third of the people in there, using thousands of dollars a month, are never going to have any significant quality of life again. It's the 92 year old with CHF, COPD, and senile dementia whose every body function is performed by a machine at incredible cost that drives much of our health care spending. Because while we just spent 10000 dollars on that, many EU countries spent 0 because futile care is rationed. That's a pretty big gap to catch up on.

You beat me to press with this one, Dino - this issue was (actually still will be) one I tackle later today and more in depth probably next week.I agree with Anon #1 - futile care *should* be rationed and families/patients *should* be required to pay a percentage of the costs of futile care if they demand it.Problem with the current system is once again people who demand the best medical care someone else can pay for. Because of this mindset, they develop unrealistic expectations or perverse incentives (getting an extra month of grandma's pension/SSI check, etc).Now how do we tackle the issue of defining "futile"?

Nice post Dino and you certainly have provided me with a different perspective which is a good thing, and to some degree true. But then again so are the points of whitecoat and anonymous 4:15, and I think it is that patient which is most frustrating. According to most state laws a physician is not obligated to provide care that is deemed futile, part of the problem is we let the families decide what is futile and/or too many physicians are too afraid to make that decision.

Mark's Tails observes, "According to most state laws a physician is not obligated to provide care that is deemed futile, part of the problem is we let the families decide what is futile and/or too many physicians are too afraid to make that decision."

James Gibson, a law professor at the University of Richmond, has a new article up on SSRN titled Doctrinal Feedback and (Un)Reasonable Care. Here is a portion of the abstract:

The law frequently derives its content from the practices of the community it regulates. . . .Yet real-world practice can depart from that which the law expects. For example, suppose a physician provides more-than-reasonable care - extra tests, unneeded procedures, etc. - so as to steer clear of tort liability's considerable gray area. If other physicians follow suit, their precautions slowly but surely become the new legal norm, as the reasonable care standard dutifully absorbs the conduct of those it governs. Instead of discouraging wasteful practices, the law feeds them back into doctrine, making overcompliance into mere compliance and racheting up the standard of care. Overcautious physicians then have to do even more to steer clear of liability, and the cycle begins anew. . . .

This is a great framework in which to understand how the threat of liability chills physicians from doing the "right" thing. Since physicians accede to inappropriate surrogate demands, they create the very standard they want to get away from.

At this point, it seems that without a change in the legal rules which are pegged to standard of care, physicians need to collectively change the standard of care itself through collective action.

Dinosaur seems to be onto just this when he writes "Eventually, physicians might feel empowered to limit aggressive care to those with very low likelihoods of survival. I know this sort of thing may be happening now on an informal basis, but if it were more systematized if might become easier to incorporate into policy."

Take the sort of case that Whitecoat describes -- a surrogate demanding aggressive treatment because of "perverse incentives (getting an extra month of grandma's pension/SSI check, etc.)."

Bob Truog has written a few pieces in NEJM explaining that this sort of futility dispute can be resolved under current health care decision making law. The surrogate is not acting according to the patient's instructions/wishes/best interests. Therefore, the surrogate can be bumped/replaced with another.

In a forthcoming article I argue that while this mechamism was unpopular during the early 1990s, it has found increasing success more recently. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1078983

I used to follow several medical blogs, including the ones you mentioned. I stopped because I was so appalled by the way patients seem to irritate the doctors/nurses who write these blogs. I'm not looking forward to the day when I will be derisively referred to as an "LOL" by the professionals who are charged with caring for me; when I will apparently be put on an endless loop between the nursing home and the ER, as everyone wonders when I will just die already and quit using up resources. And, to those who think that having families help cover costs of care will take care of the problem, I ask if you have ever had a veterinarian make you feel guilty because you had to factor in cost in your care decisions for your pet. Do you think this will not happen with an MD?

Can you forsee a time - once we've made the transition to a governmennt sponsored, single payer system - where end of life care is rationed according to governmnet policy? I do, but I'm not sure if it's a good or a bad thing.